言語治療專科服務 Speech Therapy Specialty Service

言語治療專科服務 Speech Therapy Specialty Service

香港中文大學醫學院耳鼻咽喉—頭頸外科學系歡迎閣下預約本學系的言語治療專科服務。為更了解個案的情況，請閣下或家屬填寫本表格。一切所得資料只作臨床參考之用，絕對保密。

閣下填妥表格後，本學系將會盡快處理閣下的服務預約申請，屆時將會通過電話或電郵通知閣下相關的預約資料。

Welcome to the online booking system for Speech Therapy Specialty Service, provided by the Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, The Chinese University of Hong Kong. In order to help us better understand your situation, the form should be filled out by you or your family member. All information provided will be kept strictly confidential and available only to persons who are deemed necessary to provide the speech therapy service.

After receiving your application, we will process it as soon as possible and contact you via phone/email shortly.

個人資料 Personal Information
姓氐 Surname *
名字 First Name *
出生日期 Date of birth *

DD/MM/YYYY
年齡 Age *
性別 Gender *

性別 Gender 男 Male 女 Female
聯絡人電話及關係(如非接受服務本人)
Contact Person Number & Relationship (If different from the service receiver) *
其他聯絡電話 Alternate Contact Phone Number
電郵 Email address *
所說語言 Language(s) spoken *

所說語言 Language(s) spoken 廣東話 Cantonese 普通話 Mandarin 英語 English 其他 Other 其他 Other
教育程度 Education Level
職業 Occupation
主要照顧者為 (如適用)
The primary caregiver is (if applicable)
主要照顧者與接受服務人士之關係 (如適用)
The relationship between the service receiver and the primary caregiver (if applicable)
主要照顧者以何種語言與接受服務之人士溝通 (如適用)
The language(s) of the primary caregiver communicate with the service receiver (if applicable)

主要照顧者以何種語言與接受服務之人士溝通 (如適用)
The language(s) of the primary caregiver communicate with the service receiver (if applicable) 廣東話 Cantonese 普通話 Mandarin 英語 English 其他 Other 其他 Other
健康情況 Medical History
是否曾患過嚴重疾病?
Have you ever suffered from any serious illness? *

是否曾患過嚴重疾病?
Have you ever suffered from any serious illness? 是 Yes 否 No
如是，請略述情況 If yes, please describe *
是否需要定期到專科覆診？
Do you need to see a healthcare specialist or doctor regularly? *

是否需要定期到專科覆診？
Do you need to see a healthcare specialist or doctor regularly? 需要 Yes 不需要 No
如是，請提供專科名稱
If yes, please provide the profession of the specialist *
溝通及吞嚥困難的情況
Communication and Swallowing Difficulties
請選擇一項或多項困難之情況
Please select one or more difficulties *

請選擇一項或多項困難之情況
Please select one or more difficulties 聲線問題 Voice Problem 吞嚥困難 Swallowing Difficulties 口吃 Stuttering 咬字發音困難 Speech Sound Difficulties 語言困難 Language Difficulties 認知障礙 Cognitive Impairment 聽覺障礙 Hearing difficulties 整體溝通困難 Overall Communication Difficulties 其他 Other 其他 Other
聲線問題 Voice Problem *

聲線問題 Voice Problem 沙啞 Hoarse/rough voice 失聲 Loss of voice 聲線疲勞 Fatigue Voice 聲線微弱 Soft voice 說話時感到疼痛 Pain when talking 其他 Other 其他 Other
吞嚥困難 Swallowing Difficulties *

吞嚥困難 Swallowing Difficulties 不願進食 Not willing to eat 體重減輕 Loss of weight 進食緩慢 Slow eater 流口水 Drools while eating 需要鼻管或胃管餵食
Feeds with nasogastric tube/PEG 飲食時較易嗆(濁)到 Coughs/chokes while eating 吞嚥時感到疼痛 Pain on swallowing 其他 Other 其他 Other
口吃 Stuttering *

口吃 Stuttering 重複字詞 Repeats sounds/word 句子不自然停頓 Unusual stops while talking 拖長字詞 Drags or prolongs certain sounds 面部歪扭 Facial grimaces when talking 其他 Other 其他 Other
咬字發音錯誤的例子
Examples of Speech Sound Errors *

例如: 手->抖, 狗->豆, 濕->汁；如發不到s音

For example: spoon ->poon; cannot produce /sss/ sound; drunken/slurred speech sounds
語言困難 Language Difficulties *

語言困難 Language Difficulties 表達困難 Difficulty expressing needs/wants/ideas 理解困難 Difficulty understanding instructions 其他 Other 其他 Other
左耳聽力程度 Left Ear Hearing Level *

左耳聽力程度 Left Ear Hearing Level 不詳 unknown 正常 Normal 輕度聽障 Mild Loss 中度聽障 Moderate Loss 中度至嚴重聽障 Moderate to Severe Loss 嚴重聽障 Severe Loss 深度聽障 Profound Loss
右耳聽力程度 Right Ear Hearing Level *

右耳聽力程度 Right Ear Hearing Level 不詳 unknown 正常 Normal 輕度聽障 Mild Loss 中度聽障 Moderate Loss 中度至嚴重聽障 Moderate to Severe Loss 嚴重聽障 Severe Loss 深度聽障 Profound Loss
左耳聽力儀器 Left Ear Hearing Device *

左耳聽力儀器 Left Ear Hearing Device 沒有 Nil 佩戴助聽器 Wearing Hearing Aid 佩戴人工耳蝸 Wearing Cochlear Implant 其他 Other 其他 Other
右耳聽力儀器 Right Ear Hearing Device *

右耳聽力儀器 Right Ear Hearing Device 沒有 Nil 佩戴助聽器 Wearing Hearing Aid 佩戴人工耳蝸 Wearing Cochlear Implant 其他 Other 其他 Other
預約資料 Booking Details
希望評估以何種語言進行
Preferred language(s) for the consultation *

希望評估以何種語言進行
Preferred language(s) for the consultation 廣東話 Cantonese 普通話 Mandarin 英語 English
希望約見的診所 Preferred Specialty Clinic: *

希望約見的診所 Preferred Specialty Clinic: 動態評量及認知治療診所 Dynamic assessment and Mediated Learning Experience Clinic 流暢障礙診所 Fluency Disorders Clinic 腭裂及顱面異常診所 Cleft Palate & Craniofacial Anomalies Clinic 聽力障礙診所 Hearing Impairment Clinic 神經性溝通障礙診所 Neurogenic Communication Disorders Clinic 自閉症譜系障礙之社交溝通障礙診所 Social Communication Deficits of People with Autism Spectrum Disorder Clinic 吞嚥障礙診所 Dysphagia Clinic 聲線障礙診所 Voice Disorders Clinic 語音障礙診所 Speech Sound Disorders Clinic 第二方診療意見診所 Tertiary Assessment Clinic 言語治療碩士課程學生診所 MSc Speech-Language Pathology Student Clinic 沒有偏好 No Preference
希望約見的言語治療師 Preferred Speech Therapist *

希望約見的言語治療師 Preferred Speech Therapist 李月裳教授 Professor Kathy LEE
羅家東教授 Professor Thomas LAW
Professor Valerie PEREIRA 方思行博士 Dr Raymond FONG 胡韞儀小姐 Ms Yunyi HU 簡沛淇小姐 Ms Peggy KAN 關靜然小姐 Ms Connie KWAN 林玉秋小姐 Ms Emily LAM 韋一鳳小姐 Ms Phoenix WEI 言語治療碩士課程學生 MSc Speech-Language Pathology Student 任何一位治療師皆可 Any Speech Therapist
診療模式 Consultation Format *

診療模式 Consultation Format 面授 Face-to-Face 網上 Online
希望預約的時間 Preferred Time *

希望預約的時間 Preferred Time 星期一上午 Monday AM 星期一下午 Monday PM 星期二上午 Tuesday AM 星期二下午 Tuesday PM 星期三上午 Wednesday AM 星期三下午 Wednesday PM 星期四上午 Thursday AM 星期四下午 Thursday PM 星期五上午 Friday AM 星期五下午 Friday PM 任何時間 Any Time

服務時間為星期一至五：早上9時至下午5時(最後診症時間為下午4時，星期六、日及公眾假期休息。

Our service opens at 9:00 and closes at 17:00 (last appointment time is 16:00) from Mon-Fri. Saturdays, Sundays and public holidays closed.
對是次諮詢的期望(必須填寫)
What are your expectations of the consultation? (Required) *
額外資料(如適用)
Additional information (if applicable)

任何想提供的資料

Any information you would like to provide
如有轉介信，請上載於此
Please upload if you have the referral letter

Attach Files

每次只可傳送一個檔案，每個檔案限制為5MB

Multiple files are not allowed. The maximum size of the file is limited to 5 MB.
從何處認識我們的服務?
Where do you know our service? *

從何處認識我們的服務?
Where do you know our service? 私人執業醫生轉介 Referred by private doctors 公營機構醫生轉介 Referred by Hospital Authority or Department of Health doctors 香港中文大學耳鼻喉科醫生轉介 Referred by ENT doctors, CUHK 香港中文大學保健處轉介 Referred by UHS, CUHK 香港中文大學醫院轉介 Referred by CUHK Medical Centre 親友、同事或朋友介紹 Introduced by Relatives, colleagues or friends 學校 Schools 香港言語治療師協會網頁 The Hong Kong Association of Speech Therapists Website 其他網頁 Other Website 面書 Facebook 報章雜誌 Newspaper & Magazine 其他 Other 其他 Other
是否同意讓言語治療碩士課程學生觀察診療過程?
Do you agree to let MSc Speech-Language Pathology students observe the session? *

是否同意讓言語治療碩士課程學生觀察診療過程?
Do you agree to let MSc Speech-Language Pathology students observe the session? 同意讓學生在診療室內觀察 Agree students to observe it in the clinic room 同意讓學生透過視像系統在診療室外觀察 Agree students to observe it through Observation System outside the clinic room 同意讓學生在診療室內觀察及透過視像系統在診療室外觀察 Agree students to observe it in the clinic room and through Observation System outside the clinic room 不同意 Disagree
是否同意讓言語治療碩士課程學生於診療室內協助言語治療師進行診療過程?
Do you agree to let MSc Speech-Language Pathology students assist our speech therapist to conduct the session in the clinic room ? *

是否同意讓言語治療碩士課程學生於診療室內協助言語治療師進行診療過程?
Do you agree to let MSc Speech-Language Pathology students assist our speech therapist to conduct the session in the clinic room ? 同意 Agree 不同意 Disagree
是否願意登記以接收有關我們最新活動的電郵?
Are you willing to receive emails regarding our lastest activities? *

是否願意登記以接收有關我們最新活動的電郵?
Are you willing to receive emails regarding our lastest activities? 現在登記 Register Now 不登記 Not Register 已登記 Already Registered
收集個人資料聲明
Personal Information Collection Statement

閣下所提供的資料只用於言語治療服務相關之用途。閣下有權要求查閱及更正你的個人資料，有關要求請向言語治療科提出。當我們獲得閣下的個人資料後，會把這些資料妥善地儲存在系統中，只有授權之職員方可讀取這些個人資料。我們亦保證本科職員對閣下的個人資料作高度保安及保密。

The Department will use the information provided by you for Speech Therapy related service only. You have the right to request access to and correction of your personal data. Please contact Division of Speech Therapy for the above requests. Once we have obtained your personal data, they will be maintained securely in our system. Only the authorised staff will be permitted to access to such personal data. We will also ensure compliance by our staff with the strictest standards of security and confidentiality.
聲明 Declaration *

聲明 Declaration 我已經閱讀及理解以上聲明並同意遵守。
I declare that I have read and understood the above statement and I agree to abide by it.
Disclaimer The personal data collected will be used by Dept of Otorhinolaryngology, Head and Neck Surgery_ENT-ST Division - MED (OHNS_ENT_MED) and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.